The Enhanced Recovery Programme

1. The Enhanced Recovery Programme Siobhan Kelly, CNM2. R.G.N.,H.Dip CVNS, Dip. HSM Enhanced Recovery Unit, Letterkenny General Hospital

2. Enhanced Recovery Programme • Pre-operative Assessment, planning and preparation before admission. • Reducing the physical stress of the operation. • A structured approach to immediate peri and post operative management, including pain relief. • Early mobilisation Enhanced Recovery Unit, Letterkenny General Hospital

3. Aims • to optimise and improve all aspects of a patient’s journey in peri-operative care (planned surgery). • to ensure that the patient and their family/carer are active participants in planning and managing their surgery, recovery and after care • in an environment which is conducive to high quality patient centered care. Enhanced Recovery Unit, Letterkenny General Hospital

4. to achieve better outcomes and reduced length of stay • to increase the number of patients being treated • Reduce levels of resources needed • to enhance the clinical environment, to improve job satisfaction, increase morale, improve multidisciplinary communication and team work. Enhanced Recovery Unit, Letterkenny General Hospital

5. Driver for Role Expansion • Pre planned/organised theatre lists • Nurse Led Clinics • Morning of surgery admission • Early morning discharges Enhanced Recovery Unit, Letterkenny General Hospital

6. Nurse Role Expansion Pre planned/organised theatre lists: • Planning theatre list in consultation with the Consultant • Triage list – Nurse Led clinic Anaesthetist Led clinic Enhanced Recovery Unit, Letterkenny General Hospital

7. Triage Protocol for Pre-Operative Assessment Clinic Nurse-led Anaesthetic Clinic Age < 75 ≥ 75 BMI < 40 ≥ 40 Cardiac Hx Chronic stable Angina New or unstable angina CABG or Stents Myocardial Infarction Valvular stenosis Heart failure Valve replacement Creatinine Normal Raised (ever) Diabetes NIDDM < 5 yrs NIDDM > 5 yrs IDDM Stable Unstable TIA / Stroke 1 TIA 2 or more TIA Stroke Exercise capacity > 500m < 500m Surgery type Other Laparotomy THR / TKR Patient request Patient request Anaesthetic Hx. Previous problem Anticoagulants Aspirin, Warfarin Aspirin AND Plavix Warfarin ASA class ASA III or IV Enhanced Recovery Unit, Letterkenny General Hospital

8. Nurse Led Clinics • Full Nursing Assessment (inc Discharge Planning) • Anaesthetic Assessment • Venepuncture /Pre-operative tests (for e.g. Group & Hold/ECG) using evidence based practice as per NICE Guidelines(2004) & LGH Transfusion Guidelines • Medication Advice • Carbohydrate Loading information • Education & information on preparation for surgery • Date, time of admission made in consultation with patient • Review Blood results prior to expected date of admission Enhanced Recovery Unit, Letterkenny General Hospital

9. Morning of Surgery • Reassessment of patient • Completion of documentation • Intravenous cannulation • Administer medications as per Protocols • Consultation & communication with the MDT Enhanced Recovery Unit, Letterkenny General Hospital

10. Early morning discharges “Changing practice to support service delivery” Guideline for Nurse/Midwife Facilitated Discharge Planning Health Service Executive and Office of the Nursing Services Director June 2009 Enhanced Recovery Unit, Letterkenny General Hospital

11. Clinical Discharge Criteria & Minimum Length of Stay following Elective Surgery Letterkenny General Hospital Enhanced Recovery Unit (affix patient label here) Part I: Pre-Operative Authorisation by the Surgeon: This patient may be discharged as per Clinical Discharge Criteria outlined below and also subject to a Minimum Post-Operative LOS as indicated. Clinical Discharge Criteria Instructions for Nursing Staff(Tick boxes as appropriate) Min Post-Op LOS □ Haemodynamicallystable □ 1 night □ Minimal post-op wound drainage □ 2 nights □ Able to tolerate fluids & light diet □ 3 nights □ Adequatepain relief with oral analgesia □ 4 nights □ No vomiting □ 5 nights □ No nausea (or minimal) □ 6 nights □ Mobilising well relative to pre-op status □ 7- nights □ Adequate urine output relative to pre-op status □ 8 -nights □ □ 9 -nights □ Signed: (Cons / Reg.) Date: Enhanced Recovery Unit, Letterkenny General Hospital

12. Part II: Confirmation of Planned Discharge (post-op ward round): Please proceed with planned discharge as indicated above. Additional instructions (if any): Signed: (Cons / Reg.) Date: Part III: Confirmation of Planned Discharge (day before discharge) Please proceed with planned discharge as indicated above. Signed: (Cons / Reg.) Date: Take-home analgesia packs are available from the Enhanced Recovery Unit. They may be prescribed (if appropriate) using the preceding page of this booklet. The patient should collect the pack from the Enhanced Recovery Unit on their way home. Enhanced Recovery Unit, Letterkenny General Hospital

13. Group & Hold – Trained by Haemoviglance Nurse IV Venepuncture and Cannulation –Education, training & competency development through CNME Anaesthetic Assessment/assessing Blood Results – training via Anaesthetic Department Electrocardiograms Developed Patient information leaflets ratified by LGH Editorial Committee Developed medication protocols ratified by Drugs & Therapeutic Committee. Developed Policies, Procedures and Guidelines – ratified through LGH Nursing & Midwifery PPG Committee & Multidisciplinary PPG Committee (Available on QPulse) Development of New Skills/ Competencies Enhanced Recovery Unit, Letterkenny General Hospital

14. Changing the Status Quo Bringing Consultants on board Expansion of the Role of Nursing Allocation of Beds for same day admission Challenges Enhanced Recovery Unit, Letterkenny General Hospital

15. Supports • Clinical Director/Consultant Anaesthetist • Director of Nursing and Midwifery • Assistant Director of Nursing/Service Manager • Nursing and Midwifery Practice Development Unit • Bed Managers • Multidisciplinary Support especially Allied Healthcare Professionals Enhanced Recovery Unit, Letterkenny General Hospital

16. Reduced risk of cancellation Same day admission Focus on post operative pain relief, nutrition and mobilisation Familiar surroundings, meeting the same nurses Decreased length of stay “Patient Centred Care” Benefits to the Patient Enhanced Recovery Unit, Letterkenny General Hospital

17. Benefits to LGH • Increased planned surgical patient admission • Standardisation of peri-operative tests • More productive Operating Theatre • Increase in number of same day admissions • Nurse led discharge criteria • Reduced length of stay, early morning discharge Enhanced Recovery Unit, Letterkenny General Hospital

18. Increased Multidisciplinary Teamwork and CommunicationIncreased morale and job satisfactionPatient Centred Care “Primarily due to the Role Expansion in Nursing” Enhanced Recovery Unit, Letterkenny General Hospital

19. Siobhan Kelly, CNM2 Letterkenny General Hospital Thank You for Listening Enhanced Recovery Unit, Letterkenny General Hospital